Corpening Memorial YMCA Individualized Care Plan Form

Summer 2012
This form will be utilized when a parent/guardian has indicated on the Youth Information Form that their child
will be taking a prescription medication, has a special need and or disability while participating in the YMCA
program.

CHILDS NAME: _____________________________________________

CHILDS DATE OF BIRTH ____________________

Name of Prescription Medication to be taken at the YMCA:_____________________________________________________

Expiration Date: ___________________ Time to Be Taken and Frequency: __________________________________________
Dosage Amount ________________Beginning Date: ____________________ Ending Date: ________________
Special Instructions:
_________________________________________________________________________________________________________________________________

Possible Reactions: ______________________________________________________________________________________________________

Prescribing Provider: __________________________________________________________ Phone: ______________________________
Pharmacy: ________________________________________________________________________ Phone: _____________________________
I give the YMCA staff authorization to give medicine noted above and to call the health care provider if needed.
Parent/Guardian Signature: __________________________________________ Date: _____________________
Parents/Guardians - Please note special needs, concerns and/or disabilities that are important for our staff to
be familiar with prior to your childs admittance into the program Please be specific.
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________
If the YMCA staff and/or the parents/guardians feel it is necessary, a meeting will be scheduled in advance to
discuss specific information. The YMCA program welcomes all children to the extent that it is reasonably able
to do so. A child who requires measures that constitute a fundamental alteration to the program or other
undue hardship, or a child that poses a direct threat to the health and safety of others, will not be able to
participate in the program. All children, regardless of their circumstances, are subject to YMCA disciplinary
procedures.
Office Use Only: ____YMCA is to contact family regarding admission into camp
____ Parent requests contact with YMCA staff prior to camp